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Y. Yeilova et al. Patch test results in contact dermas 471

Dicle Tp Derg / Dicle Med J www.diclemedj.org Cilt / Vol 38, No 4, 471-476

Yazma Adresi /Correspondence: Dr. Yavuz Yeilova

Silvan State Hospital of Medicine Department of Dermatology, Diyarbakr, Turkey Email: [email protected]

Copyright Dicle Tp Dergisi 2011, Her hakk sakldr / All rights reserved

Dicle Tp Dergisi / 2011; 38 (4): 471-476

Dicle Medical Journal doi: 10.5798/diclemedj.0921.2011.04.0068

ORIGINAL ARTICLE / ZGN ARATIRMA

Evaluation of patch test results in patients with contact dermatitis

Temas dermatitli hastalarda yama testi sonularnn deerlendirilmesi

Yavuz Yeilova1, Derya Umak2, Bilal Sula3

1Department of Dermatology, Silvan State Hospital, Diyarbakr, Turkey2Department of Dermatology, Bismil State Hospital, Diyarbakr, Turkey

3Department of Dermatology, Dicle University Hospital, Diyarbakr, Turkey

Geli Tarihi / Received: 15.12.2010, Kabul Tarihi / Accepted: 04.01.2011

ZET

Ama: Yama testi, allerjik kontakt dermatit tansn do-rulayan ve kontakt allerjinin sebebini bulmamz salayan

en nemli tansal yntemdir Retrospektif olarak yaplan

almamzda, blgemizde kontakt dermatitli hastalarn

yama testi sonularnn deerlendirilmesi amalanmtr.

Gere ve yntem: Kontakt dermatit tans alan hastalarn84 (%56) kadn, 66s (%44) erkek, toplam 150 hasta-

ya Avrupa standart test serisi ile yama testi yapld. Test,

Uluslararas Kontakt Dermatitis Aratrma Grubu tarafn-

dan standardize edilmitir.

Bulgular: Lezyonlarn en sk ellerde (%36) yerletii g-rld. 31i kadn (%58,4), 21i erkek (%41,6) olmak zere

toplam 72 hastada (%48) bir veya birden fazla maddeye

kar pozitif allerjik reaksiyon elde edildi. En sk reaksiyon

saptanan allerjenler ise nikel slfat (%13,3), potasyum

dikromat (%11,3) ve kobalt klorid (%8,6) idi.

Sonu: Kontak dermatite nikel hassasiyetinin daha fazlaolduu bulundu. Salkl kontrollerle karlatrldnda

kontakt dermatiti hastalarda deri yama testini daha sk

grlmtr.

Anahtar kelimeler: Kontakt dermatit, yama testi, nikelslfat

ABSTRACT

Objectives: Patch test is the most reliable method to di-agnose allergic contact dermatitis and to nd out the re-

sponsible contact allergen. The aim of this retrospective

study was to evaluate the patch test results of patients

with contact dermatitis in our region.

Materials and methods: One Hundred fty patients (84female and 66 male) with contact dermatitis were patch

tested with European standard test series. The testing

has been standardized by the international Contact Der-

matitis Research Group (ICDRG).

Results: A majority of the lesions (36%) were localizedon the hands. In 31 female (58,4%) and 21 male (4,6%)

patients (a total of 72 patients) there were positive aller-

gic reactions to at least one chemical. Nickel sulphate

(13,3%), potassium dichromate (11,3%) and cobalt chlo-

ride (8,6%) were the most often allergens reacted.

Conclusion: Nickel sensitivity is more common. Com-paring with healthy controls contact sensitization may be

more prevalent in patients with contact dermatitis.

Key words: Contact dermatitis, patch test, nickel sul-phate

INTRODUCTION

Contact dermatitis is a type IV allergic reaction thatoccurs because of direct contact of both irritant andallergic substances to the skin in persons that have

been sensitized before.1 3700 chemicals have beenreported to cause contact dermatitis. These chemi-cal molecules are generally smaller than 500 daltonsand they become allergens by binding on carrier

proteins on Langerhans cells (LH). While allergensthat might cause contact dermatitis can vary overtime, they can also show geographical and socialdifferences too.2,3

The outset, course and vehemence of contactdermatitis changes depending on the sensitivity ofthe person. Moreover, certain factors such as theduration and frequency of contact with the allergen,concentration of the substance, previous edema in

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Y. Yeilova et al. Patch test results in contact dermas472


the skin, presence of dermatitis such as purulence,burnt, eczema, varicose ulcer and stasis dermatitis,sweating, alkali nature of the skin, pressure and fric-tion regions, sensitive body parts (eyelids, ear lobes,genital, etc.), occlusion, clothing style and skin dry-

ness affect the outset, course and vehemence of con-tact dermatitis too.4

The patch test that was dened by Jadassohnin 1985 was put into use by Bloch. While apply-ing the patch test that shows the sensitivity of the

person against any substance, it is crucial to preparethe contact allergen in the appropriate concentrationand carrier, place of test, patch magnitude, provisionof occlusion, application duration and evaluation ofthe test. The differences in application and different

evaluations might cause wrong conclusions.5

Patchtest is a valuable test in respect of both diagnosingallergic contact dermatitis and also preventing thedisease and informing the patient by nding the rea-son.6

In our study, we aimed at evaluating the patchtest that is applied to the patients that have been di-agnosed with contact dermatitis in our policlinic.

MATERIALS AND METHODS

Totally 150 contact dermatitis patients that appliedto our policlinic between May 2009 and February2010 and 40 healthy persons were included in thisstudy. All patients submitted their informed consent

before participation. Ages, genders, occupations andlesion localizations of patients were noted. All ofthe patients were applied a standard allergen seriesconsisting of 28 substances (IQ Chamber Manufac-tured by Chemotechnique Diagnostics Sweden) and

patch test.7 Test wasnt applied in the presence ofactive dermatitis, topical corticosteroid in the last

week, systemic corticosteroid in the last 4 weeks,immunosuppressive medicine usage and pregnancy.It was prohibited for patients to have shower, sweator use any kind of medicine during the test. Test

place was opened after 48 hours and rst evalua-tions were made after waiting for 30 minutes. Testreadings were evaluated and recorded as (-) in noreaction; (+/-) in slight erythema, suspicious reac-tion; (+) in erythema, inltration; (++) in erythema,inltration, papule, vesicle; (+++) erythema, inl-

tration, bulla according to the criteria of Internation-

al Contact Dermatitis Research Group (ICDRG) at48th and 72nd hours.1 In the event that at least one

positive reaction is detected against a certain sub-stance, patch test was regarded as positive.

RESULTS

Totally, 56% of 150 contact dermatitis patients thatparticipated in the study were female while 44%were male whereas 45% of 40 healthy individualswere female and 55% were male. The age average ofcontact dermatitis patients were 30,8214,84 (8-78)years while age average of healthy individuals were25,8217,16 (5-69) years. When the occupationalgroups of the patients are examined, it can be seenthat 30% are housewives, 26,6% are students, 14%are farmers, 11,3% are construction workers, 10%are teachers and 4,6% are healthcare personnel.

The distribution of positive ratios in patch testis given in Table 1. In 72 (48%) of one hundred andfty patients positive reaction against at least onesubstance in patch test was detected. 41,6% of theseseventy two patients were male whereas 58,4%were female. In 7,5% of the control group, posi-tive reaction against at least one substance in patchtest was detected. In 72,2% of seventy two positiveallergic reactions 1+, In 20,8% 2+, in 1,4% 3+, in4,2% 4+ and in 1,4% 5+ reactions were detected. Of

the patients in which positive reaction was detectedagainst at least 1 substance as a result of patch test,49,6% were female and 40,4% were male. 43,3% of

patients with positive reaction against 2 substanceswere female while 46,7% were male; 100% of pa-tients with positive reaction against 3 substanceswere male, 66,7% of patients with positive reactionagainst 4 substances were female and 33,3% weremale and 100% of patients with positive reactionagainst 5 substances were female.

Table 1. Distribution of positive ratios of patch test in con-tact dermatitis patients according to genders

Number of Positive

Reactions

Total

(n=150)

Male

(n=66)

Female

(n=84)

1+ 52 21 31

2+ 15 7 8

3+ 1 1 -

4+ 3 1 2

5+ 1 - 1

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Localizations of lesions and positivity ratios ofpatch test are given in Table 2. There was hand in-volvement in 36% of patients, face involvement in20,6% of patients, hand-foot involvement in 12,6%of patients, foot involvement in 11,4% of patients,

body involvement in 10% of patients and arm-leg in-volvement in 9,4% of patients. In 48,1% of patientswith hand involvement, positivity in patch test wasdetected. The ratios of positivity are found as fol-lows: in 45,2% of patients with hand involvement,in 57,9% of patients with hand-foot involvement,in 35,3% of patients with foot involvement, 46,6%of patients with body involvement and in 57,1% of

patients with arm-leg involvement.

Table 2. Comparison of lesion localizations and patch testpositivity ratios in contact dermatitis patients

Localization Total (n=150) Patch test positivity

Hand 54 26

Hand-foot 19 11

Arm-leg 14 8

Body 15 7

Foot 17 6

Face 31 14

The substances in our test series and distribu-tion of positive reactions according to genders aresummarized in Table 3. The most frequently reactiondetected allergens are nickel sulfate and potassiumdichromate 11,3% and cobalt 8,6%. The followingsubstances are detected in following ratios in female

patients: potassium dichromate 15,1%, nickel sul-fate 10,6%, cobalt 12,1% while ratios were foundas follows in male patients; nickel sulfate 14,2%,

potassium dichromate and cobalt 8,3%.

The positive reaction detected substances inthe control group of 40 individuals and their com-

parison with the study group are shown in Table 4.In the control group, totally 4 positive results weredetected as potassium dichromate in 2 cases, PPD inone case and nickel in one case.

Table 3. Distribution of the results of patch test in contactdermatitis patients

AllergensTotal

(n=150)

Male

(n=66)

Female

(n=84)

Potassium dichromate 17 10 7

PPD* Base 10 4 6

Tiuram 4 3 1

Neomycin 3 2 1

Cobalt 13 6 7

Benzokain 3 2 1

Nickel 20 8 12

Clioquinol - - -

Colophony 6 3 3

Paraben - - -

IPPD** - - -

Wool alcohols 4 1 3

Mercapto mix - - -

Epoxy resin - - -

Peru Balsam 4 1 3

4-tert-butilphenol

formaldehyde resin1 - 1

2-merkaptobenzotiasol 3 1 2

Formaldehyde 1 - 1

Fragrance 4 1 3

Sesquiterpence

lacton mix- - -

Qaternium 15 - - -

2-Metoxyl-6-n-pentil-

4-Benzokinon- - -

Cl+Me+isoiazolinon/

Me+isoiazlolinon- - -

Budesonide 1 1

1,2-Dibromo-2,4-

dicyanobutane- - -

Liral - - -

Tixocortol-21-pivalate 3 1 2

Fragrance mix II 1 - 1

* PPD: Para-phenylendiamin, ** IPPD: Isopropylaminodi-

phenylamin

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Table 4. Comparison of the results of patch test of contactdermatitis patients and control group

AllergenStudy Group

(n=150)

Control Group

(n=150)P

Potassium dichromate 14 2 0,154

PPD* Base 27 1 0,67

Tiuram 3 -

Neomycin 2 -

Cobalt 11 -

Benzokain 2 -

Nickel 17 1 0,112

Colophony 5 -

Wool alcohols 3 -

Peru Balsam 3 -4-tert-butilphenol

formaldehyde resin1 -

2-merkaptobenzotiasol 2 -

Formaldehyde 1 -

Fragrance 3 -

Budesonide 1 -

* PPD: Para-phenylendiamin

DISCUSSION

Patch test has an important place in the diagnosis ofcontact dermatitis and determination of its cause.8,9Standard test series are formed by bringing togeth-er the most frequently encountered allergens. Inthe standard series of patch tests, there are certaingroup of allergens that are active in 80% of contactdermatitis.8,9

Neslihan et al. detected positive reaction againstat least one substance in 41% of 100 contact derma-

titis patients in their patch test.6

This ratio was fol-lowed by following researchers in relevant ratios:Hogan et al. 89,6%, Kotoyan et al. 77,9%, Tunalet al. 73,7%, Sarcaolu et al. 72%, Christophers-en et al. 63.5%, Zug et al. 51,2%, Uta et al. 50%,Demirgne et al. 50%, Zhang et al. 47,5%, Davidet al. 45.8%, Alakloby et al. 3,6%, Su et al. 29,3%.1,3, 4, 10-18 In our study, the positivity ratios against atleast one substance in the ratio of 48% in our patchtest was found to be in conformity with the litera-ture.

Tunal et al. found out that housewives cameat the rst place when they studied the relationship

of contact dermatitis patients with their occupa-tions.4 Similar ndings were reported by Uta et al.,Sarcaolu et al. and Atakan et al. too.1, 10, 19 Whenthe occupations of dermatitis patients were ques-tioned in our study, the rst place was taken by the

housewives.Tunal et al. found out the positivity of an al-

lergen in 44% of patients in which they detectedallergic reaction while positive result with morethan one substance in 56%.4 Sarcaolu et al. de-tected reaction with single substance in 61% of 72

patients.10 In our study, at least one allergen positiv-ity was detected in 72,2% of seventy two positiveallergic reactions.

Tunal et al. detected allergic reaction against at

least one substance in their patch test in 295 patientswith contact dermatitis in 76% of female and 70%of male patients.4 endr et al. detected positive al-lergic reaction against more than one substance in70,7% of female and 29,3% of male patients.6 Ba-levi et al. detected allergic reaction against at leastone substance in 33% of males and 18,7% of fe-males.8 In our study, allergic reaction against at leastone substance was detected in 58,4% of females and41,6% of males.

Uta et al. observed reactions in ratios of 21,6%for nickel sulfate, 9,6% for fragrance mix and 8,8%for cobalt chlorine in their tests containing 23 sub-stances.1 Tunal et al. detected the rst three sub-stances among 617 allergic reactions as 23% nickelsulfate, 21% potassium dichromate and 11% benzo-kain.4 Sarcaolu et al. detected positive reaction inratios of 28% nickel sulfate, 15,2% potassium di-chromate and 11,8% benzokain in their tests of 24substances.10 Hogan et al. observed allergic reactionin the ratios of 17,4% nickel sulfate, 8,7% ethylen-

diamine and 7,4% formaldehyde in their tests on 20substances.12 Kotoyan et al. detected 9,4% nickelsulfate out of 53 allergic reactions and this was fol-lowed by potassium dichromate 30,4% and PPD19%.13 Zhang et al. detected reactions in the ratios of17,9% potassium dichromate, 13,8% nickel sulfateand 10,6% cobalt chloride in their patch test with 22substances.14 Alakloby et al. detected sensitivity inthe ratio of 26,7% for nickel sulfate and 11,9% for

potassium dichromate on 101 patients.15 Zug et al.detected positivity in ratios of 28,3% nickel sulfate,

17,9% cobalt chloride, 15,3% thimerosal in their teston 391 contact dermatitis patients.16 Demirgne et

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al. detected the nickel sensitization ratio as 24%.18Atakan et al. detected sensitivity in ratios of 16,4%for nickel sulfate, 12,97% for fragrance mix and12,3% for Peru balsam in their patch test for 23 sub-stances.19 Storrs et al. reported sensitivities against

nickel, parefenilendiamin quaternium-15 and neo-mycin as a result of the patch test on contact der-matitis patients.20 Rui et al. detected positivity inthe ratios of 24,6% for nickel sulfate, 10,2% for co-

balt chloride and 8,7% for potassium dicromat.21 Inother studies, the sensitivity ratio against nickel isreported to be 10-28,3% and it is emphasized to behigher in young ages and females. The other mostfrequently encountered allergens are reported to becobalt chlorine, potassium dichromate, fragrancemix and Peru balsam.22-27 In our study, the most fre-quently detected allergens were nickel sulfate with13,3%, potassium dichromate with 11,3 and 8,6%with cobalt among 28 substances.

The most frequently reaction detected allergensin the patch test of Tunal et al. were nickel sulfatewith 28,3%, potassium dichromate with 16,6%, co-

balt chloride with 9,5% in females; and potassiumdichromate with 28,8, benzokain with 15,5 and co-

balt chloride with 9% in males.4 Balevi et al. de-tected nickel sensitivity in 24,2% of females and

4,7% of males.8 In our study, following ratios wereobtained; potassium dichromate 15,1%, nickel sul-fate 10,6% and cobalt 12,1 in female patients andnickel sulfate 14,2%, potassium dichromate and co-

balt 8,3% in male patients.

In conclusion, nickel sulfate, potassium dichro-mate and cobalt chloride were detected to causehighest sensitization in the patient group on which

patch test was applied. European standard patch testseries contain most of the contact allergens that weface frequently every day. For this reason, when al-lergic contact dermatitis is suspected, it should betested routinely.

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